Herbal Remedy or Medical Tragedy?

Abstract

This is the case of a 63—year—old Hispanic man who came to the emergency room due to right upper quadrant discomfort and yellowing of the skin for the past week. Patient denies fever, chills, nausea, vomiting, diarrhea, sick contacts at home or recent traveling however refers he began taking saw palmetto for benign prostatic hyperplasia a few months ago. Physical exam was remarkable for generalized jaundice and moderate abdominal right upper quadrant tenderness. Laboratory tests revealed elevated bilirubin in 4mg/dL, alkaline phosphatase of 181 u/L and elevated hepatic enzymes consistent with a cholestatic pattern. Abdominal CT without intravenous contrast and abdominal sonogram both unremarkable. MRCP revealed mild intrahepatic and proximal extrahepatic ductal dilatation with common bile duct measuring 2.8cm most likely secondary to prior cholecystectomy since no evidence of obstructive lesions. Toxicology negative. Work up for pre—existing liver disease was negative for viral hepatitis and autoimmune markers. Drug—induced liver injury (DILI) can develop secondary to the use of many drugs including both prescription and over—the counter. Drugs associated with DILI may cause hepatic injury in a dose—dependent way or an unforeseeable manner. DILI accounts for approximately 10 percent of all cases of hepatitis and it is the most common cause of acute liver failure in the United States. DILI is characterized by the type of hepatic injury occurred including hepatocellular injury, cholestatic injury or mixed. In this case, the DILI is considered cholestatic since the ratio of ALT/ALP is less than 2. The presence of jaundice (bilirubin >2 times the upper limit of normal) and elevation in serum aminotransferases (>3 times the upper limit of normal) is associated with a worse prognosis, as in this case. Saw palmetto is one of the most commonly use herbal remedies to treat benign prostatic hyperplasia. Even though in clinical trials liver injury associated to saw palmetto is rare, there are a few case reports in which direct liver injury secondary to Serenoa repens, colloquially known as “Saw Palmetto” is demonstrated. As it occurred in reported cases, liver injury in our patient resolved upon removal of the offending agent which was demonstrated in laboratory workup performed three months later.